Caudal epidural haemorrhagic patch: a safe alternative for spontaneous intracranial hypotension syndrome

Abstract

Introduction: In the differential diagnosis of headache, spontaneous intracranial hypotension should be considered. Initial treatment is conservative; however, it is often ineffective. An epidural blood patch is recommended if symptoms persist for more than two weeks, or earlier in cases of severe clinical presentation. Case presentation: A 24-year-old patient was admitted to the Neurology Department with bilateral pressing headache associated with neck stiffness and nausea, with a 25-day history. The patient had previously been evaluated twice in the Emergency Department without improvement despite prescribed treatment. No cerebrospinal fluid leak was identified on imaging studies. A diagnosis of spontaneous intracranial hypotension was established. Due to persistent symptoms, a caudal epidural blood patch was performed 13 days after admission, resulting in complete and immediate resolution of symptoms. The patient was discharged three days after the blood patch, asymptomatic. Discussion: In spontaneous intracranial hypotension, treatment is not standardized. Traditionally, a non-targeted epidural blood patch has been performed via the lumbar approach; however, the caudal approach is a valid and safe option, as it avoids the risk of accidental dural puncture and the consequent potential clinical worsening. Conclusion: The caudal approach may be a safer alternative to the interlaminar approach for performing an epidural blood patch; however, further studies are needed.